Aetna clinical policy bulletin dorsal column stimulation
Gabapentinoids (e.g., gabapentin and pregabalin), Dr. HCPCS codes not covered for indications listed in the CPB: HCPCS codes covered if selection criteria are met: Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes Work hardening/conditioning initial 2 hoursĮach additional hour (List separately in addition to code for primary procedure) Hand held dynamometer, auricular acupressure, cupping therapy - no specific code:Īpplication of a modality to 1 or more areas traction, mechanical Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes ĬPT codes not covered for indications listed in the CPB: Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic procedure, one or more areas, each 15 minutes therapeutic exercises to develop strength and endurance, range of motion and flexibility Table: CPT Codes / HCPCS Codes / ICD-10 Codes Code
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CPB 0204 - Manipulation Under General Anesthesia.CPB 0180 - Vertebral Axial Decompression.CPB 0016 - Back Pain - Invasive Procedures.CPB 0011 - Electrical Stimulation for Pain.Please check benefit plan descriptions for details. See CPB 0250 - Occupational Therapy and CPB 0198 - Work Hardening Programs. Spinal adjusting instruments (see CPB 0107 - Chiropractic Services).īack school for occupational purposes may be excluded from coverage.Gabapentinoids (e.g., gabapentin and pregabalin) (excluding fibromyalgia indication).Other Interventions for the Treatment of Back Pain.The use of the hand-held dynamometer is considered integral to the manual muscle testing and is not separately reimbursed. Note: No additional reimbursement is provided for performing manual muscle testing using hand-held dynamometers (not an all-inclusive list):
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JTECH Tracker Freedom Wireless Muscle Testing.Kin-Com Physical Therapy Isokinetic Equipment.MedX Lumbar and Cervical Extension Devices.The use of quantitative muscle testing devices (not an all-inclusive list) when used for muscle testing because there is insufficient evidence that use of these devices improves the assessment of muscle strength over standard manual strength testing such that clinical outcomes are improved: The following interventions are considered experimental and investigational because the effectiveness of these approaches has not been established: However, these particular brands of exercise devices have not been proven to be superior to standard brands of exercise equipment (e.g., Nautilus, etc.) when used for administering physical therapy. These devices can be used as exercise machines for administering physical therapy. In addition to use in muscle testing, the MedX and other machines have also been used for administering exercise therapy. Isokinetic devices (e.g., Biodex, Cybex, and Kin-Com) and other exercise and testing machines (e.g., Isostation B-2000 and MedX) are considered acceptable alternatives for provision of medically necessary exercise in physical therapy. This Clinical Policy Bulletin addresses non-invasive treatments for back pain.Īetna considers back school medically necessary for the treatment of persons with chronic or recurrent back pain, when such a program is prescribed by the member’s doctor and the program is conducted by a physical therapist or other appropriate recognized healthcare professional. Number: 0232 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References